Provider Demographics
NPI:1750026720
Name:MONTENEGRO, CRISTOFFER RENE SR
Entity Type:Individual
Prefix:
First Name:CRISTOFFER
Middle Name:RENE
Last Name:MONTENEGRO
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7031 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4701
Mailing Address - Country:US
Mailing Address - Phone:305-284-7761
Mailing Address - Fax:305-284-7787
Practice Address - Street 1:7031 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4701
Practice Address - Country:US
Practice Address - Phone:305-284-7761
Practice Address - Fax:305-284-7787
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-03
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2428390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program